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Periodontology or periodontics (from
Ancient Greek Ancient Greek (, ; ) includes the forms of the Greek language used in ancient Greece and the classical antiquity, ancient world from around 1500 BC to 300 BC. It is often roughly divided into the following periods: Mycenaean Greek (), Greek ...
, – 'around'; and , – 'tooth', genitive , ) is the specialty of
dentistry Dentistry, also known as dental medicine and oral medicine, is the branch of medicine focused on the Human tooth, teeth, gums, and Human mouth, mouth. It consists of the study, diagnosis, prevention, management, and treatment of diseases, dis ...
that studies supporting structures of
teeth A tooth (: teeth) is a hard, calcified structure found in the jaws (or mouths) of many vertebrates and used to break down food. Some animals, particularly carnivores and omnivores, also use teeth to help with capturing or wounding prey, tear ...
, as well as diseases and conditions that affect them. The supporting tissues are known as the
periodontium The periodontium () is the specialized tissues that both surround and support the teeth, maintaining them in the maxillary and mandibular bones. Periodontics is the dental specialty that relates specifically to the care and maintenance of the ...
, which includes the
gingiva The gums or gingiva (: gingivae) consist of the mucosal tissue that lies over the mandible and maxilla inside the mouth. Gum health and disease can have an effect on general health. Structure The gums are part of the soft tissue lining of the ...
(gums),
alveolar bone The alveolar process () is the portion of bone containing the tooth sockets on the jaw bones (in humans, the maxilla and the mandible). The alveolar process is covered by gums within the mouth, terminating roughly along the line of the mandibu ...
,
cementum Cementum is a specialized calcified substance covering the root of a tooth. The cementum is the part of the periodontium that attaches the teeth to the alveolar bone by anchoring the periodontal ligament. Structure The cells of cementum are ...
, and the
periodontal ligament The periodontal ligament, commonly abbreviated as the PDL, are a group of specialized connective tissue fibers that essentially attach a tooth to the alveolar bone within which they sit. It inserts into root cementum on one side and onto alveo ...
. A periodontist is a dentist that specializes in the prevention, diagnosis and treatment of
periodontal disease Periodontal disease, also known as gum disease, is a set of inflammatory conditions affecting the tissues surrounding the teeth. In its early stage, called gingivitis, the gums become swollen and red and may bleed. It is considered the main c ...
and in the placement of
dental implant A dental implant (also known as an endosseous implant or fixture) is a prosthesis that interfaces with the bone of the jaw or skull to support a dental prosthesis such as a crown (dentistry), crown, bridge (dentistry), bridge, dentures, denture ...
s.


The periodontium

The term ''periodontium'' is used to describe the group of structures that directly surround, support and protect the teeth. The periodontium is composed largely of the gingival tissue and the supporting bone.


Gingivae

Normal gingiva may range in color from light coral pink to heavily pigmented. The soft tissues and connective fibres that cover and protect the underlying cementum, periodontal ligament and alveolar bone are known as the gingivae. The gingivae are categorized into three anatomical groups: the free, attached and the interdental gingiva. Each of the gingival groups are considered biologically different; however, they are all specifically designed to help protect against mechanical and bacterial destruction.


Free gingiva

The tissues that sit above the alveolar bone crest are considered the free gingiva. In healthy periodontium, the gingival margin is the fibrous tissue that encompasses the cemento-enamel junction, a line around the circumference of the tooth where the enamel surface of the crown meets the outer cementum layer of the root. A natural space called the
gingival sulcus In dental anatomy, the gingival sulcus is an area of potential space between a tooth and the surrounding gingiva, gingival tissue and is lined by sulcular epithelium. The depth of the sulcus (Latin for ''groove'') is bounded by two entities: ...
lies apically to the gingival margin, between the tooth and the free gingiva. A non-diseased, healthy gingival sulcus is typically 0.5-3mm in depth, however, this measurement can increase in the presence of periodontal disease. The gingival sulcus is lined by a non-keratinised layer called the oral
sulcular epithelium In dental anatomy, the sulcular epithelium is that epithelium Epithelium or epithelial tissue is a thin, continuous, protective layer of cells with little extracellular matrix. An example is the epidermis, the outermost layer of the skin ...
; it begins at the gingival margin and ends at the base of the sulcus where the junctional epithelium and attached gingiva begins.


Attached gingiva

The
junctional epithelium In dental anatomy, the junctional epithelium (JE) is that epithelium which lies at, and in health also defines, the base of the gingival sulcus (i.e. where the gums attach to a tooth). The probing depth of the gingival sulcus is measured by a cal ...
is a collar-like band that lies at the base of the gingival sulcus and surrounds the tooth; it demarcates the areas of separation between the free and attached gingiva. The junctional epithelium provides a specialized protective barrier to microorganisms residing around the gingival sulcus. Collagen fibres bind the attached gingiva tightly to the underlying periodontium including the cementum and alveolar bone and vary in length and width, depending on the location in the oral cavity and on the individual.Newman, M., Takei, H. Klokkevold, P. R., Carranza, F. A. (2015). Carranza's Clinical Periodontology (12th ed.). St. Louis: Elsevier IncWeinberg, M., Westphal, C., Froum, S. J., Palat, M. P., & Schoor, R. S. (2010). Comprehensive Periodontics for the Dental Hygienist (3rd ed.). Upper Saddle River, N.J.: Pearson Education The attached gingiva lies between the free gingival line or groove and the
mucogingival junction A mucogingival junction is an anatomical feature found on the intraoral mucosa. The mucosa of the cheeks and floor of the mouth are freely moveable and fragile, whereas the mucosa around the teeth and on the palate are firm and keratinized. Wher ...
. The attached gingiva dissipates functional and masticatory stresses placed on the gingival tissues during common activities such as
mastication Chewing or mastication is the process by which food is comminution, crushed and ground by the teeth. It is the first step in the process of digestion, allowing a greater surface area for digestive enzymes to break down the foods. During the mast ...
, tooth brushing and speaking. In health it is typically pale pink or coral pink in colour and may present with surface stippling or racial pigmentation.


Interdental gingiva

The
interdental gingiva The interdental papilla, also known as the interdental gingiva, is the part of the gums (gingiva) that exists coronal to the free gingival margin on the mesial and distal surfaces of the teeth. The interdental papillae fill in the area between ...
takes up the space beneath a tooth contact point, between two adjacent teeth. It is normally triangular or pyramidal in shape and is formed by two interdental papillae (lingual and facial). The middle or centre part of the interdental papilla is made up of attached gingiva, whereas the borders and tip are formed by the free gingiva. The central point between the interdental papillae is called the col. It is a valley-like or concave depression that lies directly beneath the contact point, between the facial and lingual papilla. However, the col may be absent if there is gingival recession or if the teeth are not contacting. The main purpose of the interdental gingiva is to prevent food impaction during routine mastication.


Alveolar mucosa

This area of tissue is non-keratinized and is located beyond the mucogingival junction. It is less firmly attached and is redder than attached gingiva. It provides for the movement of cheek and lips.


Periodontal ligament

The
periodontal ligament The periodontal ligament, commonly abbreviated as the PDL, are a group of specialized connective tissue fibers that essentially attach a tooth to the alveolar bone within which they sit. It inserts into root cementum on one side and onto alveo ...
is the connective tissue that joins the outer layer of the tooth root, being the cementum, to the surrounding alveolar bone. It is composed of several complex fibre groups that run in different directions and which insert into the cementum and bone via
Sharpey's fibres Sharpey's fibres (bone fibres, or perforating fibres) are a matrix of connective tissue consisting of bundles of strong predominantly type I collagen fibres connecting periosteum to bone. They are part of the outer fibrous layer of periosteum ...
. The periodontal ligament is composed mostly of collagen fibres, however it also houses blood vessels and nerves within loose connective tissue. Mechanical loads that are placed on the teeth during mastication and other external forces are absorbed by the periodontal ligament, which therefore protects the teeth within their sockets.


Alveolar bone

In periodontal health, the alveolar bone surrounds the teeth and forms the bony socket that supports each tooth. The buccal and lingual plates and lining of the sockets are composed of thin, yet dense compact or cortical bone. Within the cortical plates and dental sockets lies cancellous bone, a spongy or trabecular-type bone which is less dense than compact bone. The anatomic landmarks of the alveolar process includes the lamina dura, the alveolar crest, and the periodontal ligament space.


Cementum

Cementum is the outer layer of the tooth root; it overlies the
dentin Dentin ( ) (American English) or dentine ( or ) (British English) () is a calcified tissue (biology), tissue of the body and, along with tooth enamel, enamel, cementum, and pulp (tooth), pulp, is one of the four major components of teeth. It i ...
e layer of the tooth and provides attachment for the collagen fibres of the periodontal ligament. It also protects the dentine and provides a seal for the otherwise exposed ends of the dentinal tubules. It is not as hard as enamel or dentine and is typically a light yellow colour.


Gingival diseases

Gingivitis Gingivitis is a non-destructive disease that causes inflammation of the gums; ulitis is an alternative term. The most common form of gingivitis, and the most common form of periodontal disease overall, is in response to bacterial biofilms (also ...
is a common condition that affects the gingiva or mucosal tissues that surround the teeth. The condition is a form of periodontal disease; however, it is the least devastating, in that it does not involve irreversible damage or changes to the periodontium (gingiva, periodontal ligament, cementum or alveolar bone). It is commonly detected by patients when gingival bleeding occurs spontaneously during brushing or eating. It is also characterized by generalized inflammation, swelling, and redness of the mucosal tissues. Gingivitis is typically painless and is most commonly a result of plaque
biofilm A biofilm is a Syntrophy, syntrophic Microbial consortium, community of microorganisms in which cell (biology), cells cell adhesion, stick to each other and often also to a surface. These adherent cells become embedded within a slimy ext ...
accumulation, in association with reduced or poor
oral hygiene Oral hygiene is the practice of keeping one's oral cavity clean and free of disease and other problems (e.g. bad breath) by regular brushing of the teeth (dental hygiene) and adopting good hygiene habits. It is important that oral hygiene be carr ...
. Other factors may increase a person's risk of gingivitis, including but not limited to systemic conditions such as uncontrolled diabetes mellitus and some medications. The signs and symptoms of gingivitis can be reversed through improved oral hygiene measures and increased plaque disruption. If left untreated, gingivitis has the potential to progress to periodontitis and other related diseases that are more detrimental to periodontal and general health.


Periodontal diseases

Periodontal disease encompasses a number of diseases of the periodontal tissues that result in attachment loss and destruction of alveolar bone. Periodontal diseases take on many different forms but are usually a result of a coalescence of bacterial plaque biofilm accumulation of the red complex bacteria (e.g.
P. gingivalis ''Porphyromonas gingivalis'' belongs to the phylum Bacteroidota and is a nonmotile, Gram-negative, rod-shaped, anaerobic, pathogenic bacterium. It forms black colonies on blood agar. It is found in the oral cavity, where it is implicated in per ...
, T. forsythia, and T. denticola) of the gingiva and teeth, combined with host immuno-inflammatory mechanisms and other risk factors that can lead to destruction of the supporting bone around natural teeth. Untreated, these diseases can lead to alveolar bone loss and
tooth loss Tooth loss is a process in which one or more teeth come loose and fall out. Tooth loss is normal for deciduous teeth, deciduous teeth (baby teeth), when they are replaced by a person's permanent teeth, adult teeth. Otherwise, losing teeth is unde ...
. , periodontal disease accounted for 70.8% of teeth lost in patients with the disease in South Korea. Periodontal disease is the second most common cause of tooth loss (second to dental caries) in Scotland. Twice-daily brushing and flossing are a way to help prevent periodontal diseases. Healthy gingiva can be described as stippled, pale or coral pink in Caucasian people, with various degrees of pigmentation in other races. The gingival margin is located at the cemento-enamel junction without the presence of pathology. The gingival pocket between the tooth and the gingival should be no deeper than 1–3mm to be considered healthy. There is also the absence of bleeding on gentle probing. Periodontal diseases can be caused by a variety of factors, the most prominent being dental plaque. Dental plaque forms a bacterial biofilm on the tooth surface; if not adequately removed from the tooth surface in close proximity to the gingiva, a host-microbial interaction gets underway. This results in the imbalance between host and bacterial factors which can in turn result in a change from health to disease. Other local or systemic factors can result in or further progress the manifestation of periodontal disease. Other factors can include age, socio-economic status, oral hygiene education and diet. Systemic factors may include uncontrolled diabetes or tobacco smoking. Signs and symptoms of periodontal disease: bleeding gums,
gingival recession Gingival recession, also known as gum recession and receding gums, is the exposure in the roots of the teeth caused by a loss of gum tissue or retraction of the gingival margin from the crown of the teeth.halitosis Bad breath, also known as halitosis, is a symptom in which a noticeably unpleasant breath odour is present. It can result in anxiety among those affected. It is also associated with depression and symptoms of obsessive compulsive disorder. Th ...
(bad breath), mobile teeth, ill-fitting dentures and buildup of plaque and
calculus Calculus is the mathematics, mathematical study of continuous change, in the same way that geometry is the study of shape, and algebra is the study of generalizations of arithmetic operations. Originally called infinitesimal calculus or "the ...
. Individual risk factors include: gender, smoking and alcohol consumption, diabetes, obesity and
metabolic syndrome Metabolic syndrome is a clustering of at least three of the following five medical conditions: abdominal obesity, high blood pressure, high blood sugar, high serum triglycerides, and low serum high-density lipoprotein (HDL). Metabolic syndro ...
, osteoporosis and Vitamin D conditions, stress and genetic factors.


2018 AAP/EFP classification of periodontal and peri-implant diseases and conditions

In 2017, the American Academy of Periodontology (AAP) and the European Federation of Periodontology (EFP) together collaborated to revise and adopt a new classification system for periodontal conditions to aid in a more personalized approach to patient care. In 2018 they released an updated classification system which includes a multi-dimensional staging and grading system for periodontitis classification, a recategorization of various forms of periodontitis, and the inaugural classification for peri-implant diseases and conditions.


Periodontal health, gingivitis, and gingival diseases and conditions

The 2018 Disease Classification for periodontal health, gingivitis, and gingival diseases and conditions are outlined in detail below: # Periodontal health and gingival health ## Clinical gingival health on an intact periodontium ## Clinical gingival health on a reduced periodontium ##* Stable periodontitis patient ##* Non-periodontitis patient # Gingivitis—dental biofilm-induced ## Associated with dental biofilm alone ## Medicated by systemic or local risk factors ## Drug-influenced gingival enlargement # Gingival diseases—nondental biofilm-induced ## Genetic or developmental disorders ## Specific infections ## Inflammatory and immune conditions ## Reactive processes ## Neoplasms ## Endocrine, nutritional, and metabolic diseases ## Traumatic lesions ## Gingival pigmentation


Disease classification for the three major forms of periodontitis

The 2018 Disease Classification of Periodontal Diseases and Conditions breaks down the category of periodontitis into three forms and each of these forms are further broken down into two or more subcategories. # Necrotizing periodontal diseases ## Necrotizing gingivitis ## Necrotizing periodontitis ## Necrotizing stomatitis # Periodontitis as manifestation of systemic diseases – Classification of these conditions should be based on the primary systemic disease according to the International Statistical Classification of Diseases and Related Health Problems (ICD) codes # Periodontitis ## Stages: Based on ''severity'' and ''complexity of management'' ##* Stage I: Initial periodontitis ##* Stage II: Moderate periodontitis ##* Stage III: Severe periodontitis with potential for additional tooth loss ##* Stage IV: Severe periodontitis with potential for loss of the dentition ## Extent and distribution: ''Localized, generalized; molar-incisor distribution'' ## Grades: ''Evidence or risk of rapid progression'', ''anticipated treatment response'' ##* Grade A: Slow rate of disease progression ##* Grade B: Moderate rate of disease progression ##* Grade C: Rapid rate of disease progression


Other conditions affecting the periodontium

The 2018 Disease Classification of Periodontal Disease and Conditions contains a category for other conditions that may have an effect upon the health of the periodontium. # Systemic diseases or conditions affecting the periodontal supporting tissues # Other periodontal conditions ## Periodontal abscesses ## Endodontic periodontal lesions # Mucogingival deformities and conditions around teeth ## Gingival phenotype ## Gingival/soft tissue recession ## Lack of gingiva ## Decreased vestibular depth ## Aberrant frenum or muscle position ## Gingival excess ## Abnormal colour ## Condition of exposed root surface # Traumatic occlusal forces ## Primary occlusal trauma ## Secondary occlusal trauma ## Orthodontic forces # Prostheses and tooth-related factors that modify or predispose to plaque-induced gingival diseases/periodontitis ## Localized tooth-related factors ## Localized dental prostheses-related factors


Peri-implant diseases and conditions

The 2018 Disease Classification of Periodontal Disease and Conditions divides this category into four subcategories: * Peri-implant health * Peri-implant mucositis * Peri-implantitis * Peri-implant soft and hard tissue deficiencies


Prevention

The most effective prevention method is what can be achieved by the patient at home, for example, using the correct
tooth brushing Tooth brushing is the act of scrubbing teeth with a toothbrush equipped with toothpaste. Interdental cleaning (with floss or an interdental brush) can be useful with tooth brushing, and together these two activities are the primary means of c ...
technique,
interdental cleaning Interdental cleaning or interproximal cleaning is part of oral hygiene where the aim is to clean the areas in between the teeth, otherwise known as the proximal surfaces of teeth. This is to remove the dental plaque in areas a toothbrush cannot rea ...
aids such as interdental brushes or
floss Free and open-source software (FOSS) is software available under a license that grants users the right to use, modify, and distribute the software modified or not to everyone free of charge. FOSS is an inclusive umbrella term encompassing free ...
and using a fluoridated
toothpaste Toothpaste is a paste or gel dentifrice that is used with a toothbrush to clean and maintain the aesthetics of Human tooth, teeth. Toothpaste is used to promote oral hygiene: it is an abrasive that aids in removing dental plaque and food from th ...
. It is also advised that patients receive bi-annual check ups from their dental health provider along with thorough cleaning.


Treatment

Along with specialist periodontist treatment, a general dentist or
dental hygienist A dental hygienist or oral hygienist is a licensed dental professional, registered with a dental association or regulatory body within their country of practice. Prior to completing clinical and written board examinations, registered dental hygie ...
can perform routine scale and cleans using either hand instruments or an ultrasonic scaler (or a combination of both). The practitioner can also prescribe specialized plaque-removal techniques (tooth brushing, interdental cleaning). The practitioner can also perform a plaque index to indicate to the patient areas of plaque they are not removing on their own. This can be removed through the procedure of a dental prophylaxis.


Aetiology

The primary aetiological factor for periodontal disease is plaque biofilm of dental biofilm. A dental biofilm is a community of microorganisms attached to a hard, non-shedding surface. In the oral cavity, hard non-shedding surfaces include teeth, dental restorative materials and fixed or removable dental appliance such dentures. It is this adherence to non-shedding surfaces that allows bacteria in a dental biofilm to have unique characteristics of clinical significance. The stages of biofilm formation: # Formation of an acquired pellicle: involves selective absorption of salivary and GCF molecules through an electrostatic affinity with
hydroxyapatite Hydroxyapatite (International Mineralogical Association, IMA name: hydroxylapatite) (Hap, HAp, or HA) is a naturally occurring mineral form of calcium apatite with the Chemical formula, formula , often written to denote that the Crystal struc ...
. # Bacterial transportation: bacteria will readily adhere to the
acquired pellicle The dental pellicle, or acquired pellicle, is a protein film that forms on the surface Tooth enamel, enamel, dentin, artificial crowns, and bridges by selective binding of glycoproteins from saliva that prevents continuous deposition of salivary ca ...
through
adhesins Bacterial adhesins are cell-surface components or appendages of bacteria that facilitate adhesion or adherence to other cells or to surfaces, usually in the host they are infecting or living in. Adhesins are a type of virulence factor. Adherence is ...
, proteins and enzymes within one to two hours. # Reversible interaction: there is electrostatic attraction or hydrophobic interaction between microorganisms and the tooth surface. # Irreversible interaction: bacterial adhesins recognise specific host receptors such as pili and outer membrane proteins. The different species of bacteria bind together and require specific receptors to interact with the pellicle. # Co-adhesion: there is a natural affinity for oral microorganisms to adhere to one another which is termed co‐adhesion. Co-adhesion involves the adherence of planktonic or single culture cells to already attached organisms on a surface. The organisms which make first contact with the surface and allow the platform for later co-adhesion of bacteria are called early colonisers; they facilitate the formation of complex multispecies dental biofilms. # Multiplication: through continued growth and maturation of existing plaque micro-organisms and the further recruitment of later colonisers. # Climax community (homeostasis): after a prolonged period of stability, the bacterial community has sufficient nutrients and protection to survive. These complex biofilms are usually found in hard to cleanse areas. Nutrition is provided from dietary consumption of the host for supra-gingival biofilm organisms and from blood and GCF for the sub gingival biofilm organisms. # Detachment: from one surface to another or within biofilm allows colonization at remote sites. Bacteria contained within the biofilm are protected by a slimy extracellular polysaccharide matrix which helps to protect them from the outside environment and chemotherapeutics agents. An example of a chemotherapeutic agent is an antiseptic such as chlorhexidine mouth-rinse or antibiotics. Thus, antibiotics are not generally used in the treatment of periodontal disease, unlike other bacterial infections around the body. The most effective way to control the plaque biofilm is via mechanical removal such as toothbrushing, interdental cleaning or periodontal debridement performed by a dental professional.


Pathogenesis

An individual's
host response The immune system is a network of biological systems that protects an organism from diseases. It detects and responds to a wide variety of pathogens, from viruses to bacteria, as well as cancer cells, parasitic worms, and also objects such as w ...
plays an important role in the
pathogenesis In pathology, pathogenesis is the process by which a disease or disorder develops. It can include factors which contribute not only to the onset of the disease or disorder, but also to its progression and maintenance. The word comes . Descript ...
of periodontal disease. Even in a mouth where the gingiva appear healthy, there is constant low-level inflammatory response facilitated by the host to manage the constant bacterial load of plaque micro-organisms. Leukocytes and neutrophils are the main cells that
phagocytose Phagocytosis () is the process by which a cell uses its plasma membrane to engulf a large particle (≥ 0.5 μm), giving rise to an internal compartment called the phagosome. It is one type of endocytosis. A cell that performs phagocytosis is c ...
bacteria found in the gingival crevice or pocket. They migrate from the tissues in a specialized exudate called gingival crevicular fluid also known as GCF. Neutrophils are recruited to the gingival crevice area as they are signalled to by molecules released by plaque microorganisms. Damage to epithelial cells releases cytokines which attract leukocytes to assist with the inflammatory response. The balance between normal cell responses and the beginning of gingival disease is when there is too much plaque bacteria for the neutrophils to phagocytose and they degranulate, releasing toxic enzymes that cause tissue damage. This appears in the mouth as red, swollen and inflamed gingiva which may bleed when probed clinically or during tooth brushing. These changes are due to increased capillary permeability and an influx of inflammatory cells into the gingival tissues. When gingival disease remains established and the aetiology is not removed, there is further recruitment of cells such as macrophages, which assist with the phagocytic digestion of bacteria, and lymphocytes, which begin to initiate an immune response. Pro-inflammatory cytokines are produced inside the gingival tissues and further escalate inflammation, which impacts the progression of chronic systemic inflammation and disease. The result is collagen breakdown, infiltrate accumulation as well as collagen breakdown in the periodontal ligament and alveolar bone resorption. At this stage, the disease has progressed from gingivitis to periodontitis and the loss of supporting periodontium structure is irreversible.


Risk factors

A risk factor is a variable that in health can be defined as "a characteristic associated with an increased rate of a subsequently occurring disease". Risk factors are variables that contribute to disease, rather than being factors that induce disease. Risk factors may be seen as modifiable and non-modifiable. Modifiable risk factors are often behavioural in nature and can be changed by the individual or environmental circumstances, whereas non-modifiable factors are usually intrinsic to an individual's genetics and cannot be changed. To determine risk factors for a disease, evidence-based research and studies are needed for evidence, with longitudinal studies giving the most statistically significant outcomes and the best reliability for determining risk factors. Risk factors often coexist with other variables, rarely acting alone to contribute to a disease. Risk factors can be genetic, environmental, behavioural, psychological, and demographic in nature. There are many risk factors that contribute to placing an individual at higher risk for developing gingival and periodontal diseases. However, the only aetiological factor for periodontal disease is bacterial plaque, or biofilm. Identification of one's risk factors plays an important role in the diagnosis, treatment and management of periodontal diseases. It was previously believed that each human being had the same risk of developing periodontal diseases, but through the identification and classification of risk factors, it has become well understood that each individual will have a differing array of risk factors that generate susceptibility and contribute to severity of periodontal disease. Individual, modifiable risk factors include: *
Tobacco smoking Tobacco smoking is the practice of burning tobacco and ingesting the resulting smoke. The smoke may be inhaled, as is done with cigarettes, or released from the mouth, as is generally done with pipes and cigars. The practice is believed to hav ...
: tobacco smoking is firmly established as a major risk factor for periodontal disease, with the relationship between smoking exposure and periodontal tissue destruction being supported strongly by various research papers. Smoking decreases the healing abilities of the oral tissues by destroying blood vessels and supply and preventing essential immune-defence organisms from penetrating the tissues. Therefore, pathogenic bacteria are able to destruct the periodontal tissues more rapidly and escalate the severity of disease. Although the clinical signs of inflammation are less pronounced, smokers have a larger portion of sites with deep pocketing depths and loss of clinical attachment when compared with nonsmokers. Smoking cessation and counselling is an integral part of a dental professional's work with periodontal disease patients. Smoking cessation has been proven to prevent progression of periodontal disease and to return the oral microflora to a less pathogenic microbial state. *
Alcohol consumption Drinks containing alcohol (drug), alcohol are typically divided into three classes—beers, wines, and Distilled beverage, spirits—with alcohol content typically between 3% and 50%. Drinks with less than 0.5% are sometimes considered Non-al ...
: more research needs to be conducted in the form of longitudinal studies on the effects of alcohol on the periodontal tissues. However, current studies suggest that alcohol consumption moderately increases one's risk for progression of periodontal disease. *
Diabetes mellitus Diabetes mellitus, commonly known as diabetes, is a group of common endocrine diseases characterized by sustained hyperglycemia, high blood sugar levels. Diabetes is due to either the pancreas not producing enough of the hormone insulin, or th ...
: diabetes falls under the category of modifiable risk factors as although it cannot be cured, it can be controlled, which greatly helps periodontal disease control. A clear two-way relationship has been established with blood glucose control directly affecting periodontal disease severity and progression, and vice versa. Periodontal disease patients with diabetes mellitus also have poorer healing abilities than those without diabetes, and hence are at an increased risk for more severe diseases if blood glucose control is poor and when healing abilities are affected by systemic disease. *
Obesity Obesity is a medical condition, considered by multiple organizations to be a disease, in which excess Adipose tissue, body fat has accumulated to such an extent that it can potentially have negative effects on health. People are classifi ...
and
vitamin D deficiency Vitamin D deficiency or hypovitaminosis D is a vitamin D level that is below normal. It most commonly occurs in people when they have inadequate exposure to sunlight, particularly sunlight with adequate ultraviolet B rays (UVB). Vitamin D def ...
are both risk factors for periodontal disease that go hand in hand. Obesity is generally associated with a decreased consumption of fruits and vegetables, with an increase in foods high in fat, salt and sugar. Having a poor diet not only contributes to obesity but also results in a lack of essential nutrients, including vitamin C, D, and calcium, which all play important roles in ensuring a healthy immune system and healthy oral tissues and bone. * Poor oral hygiene: as plaque is the only aetiological factor for periodontal disease, poor oral hygiene is the most prominent risk factor in initiating, progressing and determining severity of disease. Performing brushing and interdental cleaning is perhaps one of the most effective ways at removing dental plaque biofilm and prevention of periodontal diseases. *
Cardiovascular disease Cardiovascular disease (CVD) is any disease involving the heart or blood vessels. CVDs constitute a class of diseases that includes: coronary artery diseases (e.g. angina, heart attack), heart failure, hypertensive heart disease, rheumati ...
: not only does poor oral hygiene have a clear relationship with an increased risk of developing cardiovascular disease, high concentrations of cholesterol and the mechanisms of oral bacteria in the process of atherosclerosis may increase in individuals with chronic periodontitis. * Stress: various studies have demonstrated that individuals under psychological, ongoing chronic stress are more likely to have clinical attachment loss and decreased levels of alveolar bone due to periodontal destruction. This is due to the increased production of certain immune cells and interleukins, which decrease the defensive mechanisms against pathogenic bacteria, therefore increasing chances of developing periodontal disease. *
Pregnancy Pregnancy is the time during which one or more offspring gestation, gestates inside a woman's uterus. A multiple birth, multiple pregnancy involves more than one offspring, such as with twins. Conception (biology), Conception usually occurs ...
: studies have shown that the oral tissues are affected and altered during pregnancy due to a decreased immune response and increased vascular blood supply and volume systemically. it is important to note that pregnancy does not cause gingival and periodontal diseases but may exacerbate the inflammatory response to a pre-existing disease. It is also important to note that pregnancy does not detract minerals from the oral tissues or teeth as previously thought and heard in old wives' tales. Existing disease often presents during pregnancy due to an altered oral environment, and not merely due to pregnancy causing disease. These effects can be prevented by good oral hygiene through toothbrushing and interdental cleaning. Non-modifiable risk factors include: *
Genetics Genetics is the study of genes, genetic variation, and heredity in organisms.Hartl D, Jones E (2005) It is an important branch in biology because heredity is vital to organisms' evolution. Gregor Mendel, a Moravian Augustinians, Augustinian ...
and the host response have been shown to play an important role in periodontal disease development in studies on identical twins and isolated indigenous populations. Periodontal disease also may result due to an abnormal or decreased immune response, rather than aggressive properties of bacterial pathogens. *
Osteoporosis Osteoporosis is a systemic skeletal disorder characterized by low bone mass, micro-architectural deterioration of bone tissue leading to more porous bone, and consequent increase in Bone fracture, fracture risk. It is the most common reason f ...
: in individuals with osteoporosis, studies have shown that alveolar bone is less dense than in a healthy adult. However, this does not demonstrate a relationship with periodontal pathogens or clinical attachment loss, therefore more research is needed to investigate if osteoporosis is a true risk factor for periodontal disease. * Drug-induced disorders: many drugs and medications can have an adverse effect on the periodontal tissues, through contributing to various oral conditions such as
dry mouth Xerostomia, also known as dry mouth, is a subjective complaint of dryness in the mouth, which may be associated with a change in the composition of saliva, reduced salivary flow, or have no identifiable cause. This symptom is very common and is o ...
and
gingival enlargement Gingival enlargement is an increase in the size of the gingiva (gums). It is a common feature of gingival disease. Gingival enlargement can be caused by a number of factors, including inflammatory conditions and the side effects of certain medica ...
(gingival hyperplasia). It is crucial that dental professionals ensure that poly-pharmacy patients have medical history reviewed at each visit to correctly evaluate the patient's risk and determine appropriate course of action for dental treatment. * Haematological disorders: important cells and nutrients carried in the blood to the periodontal tissues are crucial for the tissues' defence mechanisms and response to toxins and pathogens, gas exchange and efficient hemostasis. Therefore, red blood cells have a pivotal role in maintaining the health of the periodontium, meaning haematological disorders can have profound detriment to the periodontal tissues and the onset of disease. Risk characteristics must be considered in conjunction with risk factors as variables that may also contribute to increasing or decreasing one's chances of developing periodontal disease. Numerous studies show that age,
gender Gender is the range of social, psychological, cultural, and behavioral aspects of being a man (or boy), woman (or girl), or third gender. Although gender often corresponds to sex, a transgender person may identify with a gender other tha ...
, race,
socioeconomic status Socioeconomic status (SES) is a measurement used by economics, economists and sociology, sociologsts. The measurement combines a person's work experience and their or their family's access to economic resources and social position in relation t ...
,
education Education is the transmission of knowledge and skills and the development of character traits. Formal education occurs within a structured institutional framework, such as public schools, following a curriculum. Non-formal education als ...
and genetics also have strong relationships on influencing periodontal disease. Periodontal disease is multifactorial, requiring dental and oral health professionals to have a clear and thorough understanding of the risk factors and their mechanisms in order to implement effective disease management in clinical practice.


Diagnosis

Periodontitis and associated conditions are recognised as a wide range of inflammatory diseases that have unique symptoms and varying consequences. In order to identify disease, classification systems have been used to categorize periodontal and gingival diseases based on their severity,
aetiology Etiology (; alternatively spelled aetiology or ætiology) is the study of causation or origination. The word is derived from the Greek word ''()'', meaning "giving a reason for" (). More completely, etiology is the study of the causes, origin ...
and treatments. Having a system of classification is necessary to enable dental professionals to give a label to a patient's condition and make a ''periodontal diagnosis.'' A diagnosis is reached by firstly undertaking thorough examination of the patient's medical, dental and social histories, to note any predisposing risk factors (see above) or underlying systemic conditions. Then, this is combined with findings from a thorough intra and extra oral examination. Indices such as the periodontal screening record (PSR) and the Community Periodontal Index of Treatment Needs (CPITN) are also used in making a diagnosis and to order or classify the severity of disease. If disease is identified through this process, then a full periodontal analysis is performed, often by dental hygienists, oral health therapists, or specialist
periodontists Periodontology or periodontics (from Ancient Greek , – 'around'; and , – 'tooth', genitive , ) is the specialty of dentistry that studies supporting structures of teeth, as well as diseases and conditions that affect them. The supportin ...
. This involves full mouth periodontal probing and taking measurements of pocket depths, clinical attachment loss and recession. Along with this other relevant parameters such as plaque, bleeding, furcation involvement and mobility are measured to gain an overall understanding of the level of disease.
Radiographs Radiography is an imaging technique using X-rays, gamma rays, or similar ionizing radiation and non-ionizing radiation to view the internal form of an object. Applications of radiography include medical ("diagnostic" radiography and "therapeu ...
may also be performed to assess alveolar bone levels and levels of destruction.


Treatment


Phases of periodontal therapy

Contemporary periodontal treatment is designed based on the trimeric model, and is performed in four phases. These phases are structured to ensure that periodontal therapy is conducted in a logical sequence, consequently improving the
prognosis Prognosis ( Greek: πρόγνωσις "fore-knowing, foreseeing"; : prognoses) is a medical term for predicting the likelihood or expected development of a disease, including whether the signs and symptoms will improve or worsen (and how quickly) ...
of the patient, in comparison to indecisive treatment plan without a clear goal.


Phase I therapy (initial therapy – disease control phase)


=Non-surgical phase

= The non-surgical phase is the initial phase in the sequence of procedures required for periodontal treatment. This phase aims to reduce and eliminate any gingival inflammation by removing dental plaque and calculus, restoration from
tooth decay Tooth decay, also known as caries,The word 'caries' is a mass noun, and is not a plural of 'carie'.'' is the breakdown of teeth due to acids produced by bacteria. The resulting cavities may be a number of different colors, from yellow to black ...
and correction of defective restoration, as these all contribute to gingival inflammation, also known as ''gingivitis''. Phase I consists of treatment of emergencies, antimicrobial therapy, diet control, patient education and motivation, correction of
iatrogenic Iatrogenesis is the causation of a disease, a harmful complication, or other ill effect by any medical activity, including diagnosis, intervention, error, or negligence." Iatrogenic", ''Merriam-Webster.com'', Merriam-Webster, Inc., accessed 27 ...
factors, deep
caries Tooth decay, also known as caries,The word 'caries' is a mass noun, and is not a plural of 'carie'.'' is the breakdown of teeth due to acids produced by bacteria. The resulting cavities may be a number of different colors, from yellow to black ...
, hopeless teeth, preliminary scaling, temporary splinting, occlusal adjustment, minor
orthodontic Orthodontics (also referred to as orthodontia) is a dentistry specialty that addresses the diagnosis, prevention, management, and correction of mal-positioned teeth and jaws, as well as misaligned bite patterns. It may also address the modificati ...
tooth movement and
debridement Debridement is the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue. Removal may be surgical, mechanical, chemical, autolytic (self-digestion), or by maggot therapy. In ...
.


=Re-evaluation phase

= During this phase, patients are seen 3–6 weeks after initial therapy; it is required to re-evaluate the steps carried out after the phase I therapy. Usually 3–6 week re-evaluation is crucial in severe cases of periodontal disease. The elements which are required to be re-evaluated are the results of initial therapy (phase I therapy), oral hygiene and status, bleeding and plaque scores and a review of
diagnosis Diagnosis (: diagnoses) is the identification of the nature and cause of a certain phenomenon. Diagnosis is used in a lot of different academic discipline, disciplines, with variations in the use of logic, analytics, and experience, to determine " ...
and prognosis and modification of the whole treatment plan if necessary.


Phase II therapy (surgical phase)

After post-phase I, it is necessary to evaluate the requirement of periodontium for surgery. Factors identifying if the surgical phase is required are: periodontal pocket management in specific situations, irregular bony contours or deep craters, areas of suspected incomplete removal of local deposits, degree II and III furcation involvements,
distal Standard anatomical terms of location are used to describe unambiguously the anatomy of humans and other animals. The terms, typically derived from Latin or Greek roots, describe something in its standard anatomical position. This position provi ...
areas of last molars with expected mucogingival junction problems, persistent inflammation, root coverage and removal of gingival enlargement.


Phase III therapy (restorative phase)

During this phase, any defects need to be restored with removable or fixed through
dental prosthesis A dental prosthesis is an intraoral (inside the Human mouth, mouth) prosthesis used to dental restoration, restore (reconstruct) intraoral defects such as missing Human tooth, teeth, missing parts of teeth, and missing soft or hard structures of ...
,
prosthodontics Prosthodontics, also known as dental prosthetics or prosthetic dentistry, is the area of dentistry that focuses on dental prostheses. It is one of 12 dental specialties recognized by the American Dental Association (ADA), Royal College of Sur ...
, or other restoration processes.


Phase IV therapy (maintenance phase)

The last phase of periodontal therapy requires the preservation of periodontal health. In this phase, patients are required to re-visit through a scheduled plan for maintenance care to prevent any re-occurrence of the disease. The maintenance phase constitutes the long-term success for periodontal treatment, thus contributing to a long relationship between the oral health therapist,
dentist A dentist, also known as a dental doctor, dental physician, dental surgeon, is a health care professional who specializes in dentistry, the branch of medicine focused on the teeth, gums, and mouth. The dentist's supporting team aids in provi ...
, or
periodontist Periodontology or periodontics (from Ancient Greek , – 'around'; and , – 'tooth', genitive , ) is the specialty of dentistry that studies supporting structures of teeth, as well as diseases and conditions that affect them. The supportin ...
and the
patient A patient is any recipient of health care services that are performed by Health professional, healthcare professionals. The patient is most often Disease, ill or Major trauma, injured and in need of therapy, treatment by a physician, nurse, op ...
.


Periodontal and restorative interface

The prognosis of the restorative treatment is determined by the periodontal health. The goals for establishing periodontal health prior to restorative treatment are as follows: # Periodontal treatment should be managed to assure the establishment of firm gingival margin prior to tooth preparation for restoration. Absence of bleeding tissue during restorative manipulation provides accessibility and aesthetic outcome. # Certain periodontal treatment is formulated to increase sufficient tooth length for retention. Failure to accomplish these methods prior restorations can lead to the complexity or risk of failure of treatment such as impression making, tooth preparation and restoration. # Periodontal therapy should follow restorative method as the resolution of gingival inflammation may result in the repositioning of teeth or in soft tissue and mucosal changes.


Standard of periodontal treatment

Non-surgical therapy is the golden standard of periodontal therapy which consists of debridement with a combination of oral-hygiene instructions and patient motivation. It mainly focuses on the elimination and reduction of putative
pathogens In biology, a pathogen (, "suffering", "passion" and , "producer of"), in the oldest and broadest sense, is any organism or agent that can produce disease. A pathogen may also be referred to as an infectious agent, or simply a germ. The term ...
and shifting the microbial flora to a favourable environment to stabilize periodontal disease. Debridement is thorough mechanical removal of calculus and dental biofilm from the root surfaces of the tooth. Debridement is the basis of treatment for inflammatory periodontal diseases and remains the golden standard for surgical and non-surgical treatment in the initial therapy. It is conducted by hand instrumentation such as curettes or scalers and ultrasonic instrumentation. It requires a few appointments, depending on time and clinician skills, for effective removal of supragingival and subgingival calculus, when periodontal pockets are involved. It can assist in periodontal healing and reduce periodontal pocketing by changing the subgingival ecological environment. Prevention of periodontal disease and maintenance of the periodontal tissues following initial treatment requires the patient's ability to perform and maintain effective dental plaque removal. This requires the patient to be motivated in improving their oral hygiene and requires behaviour change in terms of tooth brushing, interdental cleaning, and other oral hygiene techniques. Personal oral hygiene is often considered an essential aspect of controlling
chronic periodontitis Chronic periodontitis is one of the seven categories of periodontitis as defined by the American Academy of Periodontology 1999 classification system. Chronic periodontitis is a common disease of the oral cavity consisting of chronic inflammation ...
. Research has shown that it is important to appreciate the motivation of the patient behaviour changes that have originated from the patient. Patients must want to improve their oral hygiene and feel confident that they have the skills to do so. It is crucial for the clinician to encourage patient changes and to educate the patient appropriately.
Motivational interviewing Motivational interviewing (MI) is a counseling approach developed in part by clinical psychologists William R. Miller and Stephen Rollnick. It is a directive, client-centered counseling style for eliciting behavior change by helping clients to e ...
is a good technique to ask open-ended questions and express empathy towards the patient.


Role of the oral health therapist

An oral health therapist is a member of the dental team who is dual-qualified as a dental hygienist and
dental therapist A dental therapist is a member of the dental team who provides preventive and restorative dental care for children and adults. The precise role varies and is dependent on the therapist's education and the various dental regulations and guideline ...
. They work closely with dentists and a number of dental specialists including periodontists. It is common for the oral health therapist to be involved in the treatment of gingival and periodontal diseases for patients. Their scope of practice in this area includes oral health assessment, diagnosis, treatment and maintenance and referral where necessary. They also have expertise in providing oral health education and promotion to support the patient to maintain their at-home oral care. Oral health therapists are employed by the dental team to share the responsibilities of care. They are an important asset as they have been uniquely and specifically trained in preventative dentistry and risk minimization. This allows the dental team to work more competently and effectively as dentists can manage more complex treatments or significantly medically compromised patients.


Periodontist

A periodontist is a specialist dentist who treats patients for periodontal-related diseases and conditions. They are involved in the prevention, diagnosis and treatment of periodontal disease. Periodontists receive further specialist training in periodontics after completing a dental degree. Periodontists provide treatments for patients with severe gingival diseases or complex medical histories. Periodontists offer a wide range of treatments including root scaling and planing, periodontal surgery, implant surgery and other complex periodontal procedures.American Academy of Periodontology. (2019). What is a periodontist?. Retrieved from https://www.perio.org/consumer/what-is-a-periodontist List of procedures performed by a periodontist: * non-surgical treatments * gum graft surgery * laser treatment * regenerative procedures * dental crown lengthening * dental implants * pocket reduction procedures * plastic surgery procedures


Training

Before applying to any postgraduate training program in periodontology, one must first complete a
dental degree A number of professional degrees in dentistry are offered by dental schools in various countries around the world. Degrees Dental degrees may include: Bachelor's degree * Bachelor of Dental Surgery (BDS) * Bachelor's degree of Dentistry (BDS ...
.


Canada

Canadian programs are accredited by the Commission on Dental Accreditation of Canada and are a minimum of three years in length and usually culminate with a master (MSc or MDent) degree. Graduates are then eligible to sit for the fellowship exams with the
Royal College of Dentists of Canada The Royal College of Dentists of Canada (RCDC, the College; ) is the Canadian national organization dedicated to maintaining high standards of practice and promoting excellence in dental specialties. Established in 1965, the RCDC aims to ensure ...
. Dentistry is a regulated profession. To become a licensed dentist in Canada one must have a BDS, DDS, or DMD degree and be certified by the National Dental Examining Board of Canada.


United States

The
American Dental Association The American Dental Association (ADA) is an American professional dental association. Established in 1859 and with over 159,000 current members, ADA is the world's largest and oldest national dental association. The organization lobbies on behal ...
(ADA)-accredited programs are a minimum of three years in length. According to the American Academy of Periodontology, U.S.-trained periodontists are specialists in the prevention, diagnosis and treatment of periodontal diseases and oral inflammation, and in the placement and maintenance of dental implants. Many periodontists also diagnose and treat oral pathology. Historically, periodontics served as the basis for the speciality of
oral medicine An oral medicine or stomatology doctor/dentist (or stomatologist) has received additional specialized training and experience in the diagnosis and management of oral mucosal abnormalities (growths, ulcers, infection, allergies, immune-mediated an ...
. Following successful completion of post-graduate training a periodontist becomes board-eligible for the American Board of Periodontology examination.


Maintenance

After periodontal treatment, whether it be surgical or non-surgical, maintenance periodontal therapy is essential for a long-term result and stabilization of periodontal disease. There is also a difference in the maintenance of different types of periodontal disease, as there are different types, such as:


Gingivitis

The reversible inflammation of the gums is easily prevented by patients. After the removal of the inflammatory product, usually plaque or calculus, this allows the gums room to heal. This is done by patients thoroughly cleaning teeth every day with a soft bristle toothbrush and an interdental aid. This can be floss, interdental brushes, or whatever is preferred by the patient. Without patient compliance and constant removal of plaque and calculus, gingivitis cannot be treated completely and can progress to irreversible periodontitis.


Necrotizing ulcerative gingivitis (NUG)

Also
acute necrotizing ulcerative gingivitis Necrotizing gingivitis (NG) is a common, non-contagious infection of the gums with sudden onset. The main features are painful, bleeding gums, and ulceration of interdental papillae (the sections of gum between adjacent teeth). This disease, al ...
and necrotizing ulcerative periodontitis, it is a type of periodontal disease different than many other periodontal diseases. Clinical characteristics include gingival necrosis (breakdown of the gums), gingival pain, bleeding, halitosis (bad breath), as well as a grey colour to the gingiva and a punched out appearance. It is treated through debridement, usually under local anaesthetic due to immense pain. To maintain and treat the condition completely, a
chlorhexidine Chlorhexidine is a disinfectant and antiseptic which is used for skin disinfection before surgery and to disinfect surgical instruments. It is also used for cleaning wounds, preventing dental plaque, treating yeast infections of the mouth, and ...
mouthwash should be recommended to the patient to use twice daily, oral health instruction should be provided (using a soft bristle toothbrush or electric toothbrush twice a day) and an interdental cleaning aid, such as floss or interdental brushes, which cleans the areas that the toothbrush cannot reach. The patient should also be educated on proper nutrition and diet and healthy fluid intake. Smoking cessation should occur not only to completely eradicate the disease but also for the health of the patient. Pain control can be done through ibuprofen or paracetamol/acetaminophen. In the case of an immunocompromised patient, antibiotics should be prescribed. Assessment of treatment should be done after 24 hours of treatment and continued every 3–6 months until signs and symptoms are resolved and gingival health and function restored.


Chronic periodontitis

The inflammation of the gums and irreversible destruction of the alveolar bone and surrounding structures of the teeth, which is usually slow progressing but can have bursts. Local factors explain presence of disease, such as diet, lack of oral hygiene, plaque accumulation, smoking, etc. It is characterized by pocket formation and recession of the gingiva (shrinkage of the gums). Treatment and maintenance are important in stopping disease progression and to resolve the inflammation. Treatment usually consists of scaling and root planning, surgical therapy, and regenerative surgical therapy. After treatment, patient care and regular maintenance check-ups are important to completely eradicate the disease and present its recurrence. This is done through plaque control and removal: twice daily toothbrushing and daily interdental cleaning; chlorhexidine mouthwash can also be effective. The patient should also present to a dentist for maintenance check-ups at least every three months for an in-office check-up and if necessary, plaque control.


See also

*
Bone grafting Bone grafting is a type of transplantation used to replace missing bone tissue or stimulate the healing of fractures. This surgical procedure is useful for repairing bone fractures that are extremely complex, pose a significant health risk to the ...
*
Gingival graft In periodontology, gingival grafting, also called gum grafting or periodontal plastic surgery, is a generic term for the performance of any of a number of surgical procedures in which the Gums, gingiva (gum tissue) is Graft (surgery), grafted. Th ...
*
Periodontitis Periodontal disease, also known as gum disease, is a set of inflammatory conditions affecting the tissues surrounding the teeth. In its early stage, called gingivitis, the gums become swollen and red and may bleed. It is considered the main c ...
*
Sinus lift Maxillary sinus floor augmentation (also known as a sinus lift, sinus graft, sinus augmentation, or sinus procedure) is a Surgery, surgical procedure to increase the amount of bone in the upper back part of the jaw (Commonly used terms of relat ...


Explanatory notes


References


External links


AAP Directory of Periodontists

American Academy of Periodontology's (AAP) article on Periodontal Disease

British Society of Periodontology

Canadian Academy directory of Periodontists
*
European Federation of Periodontology

The National Institute of Cranialfacial Research's article on Periodontal Disease

South African Society for Periodontology
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